A randomized single-blind controlled trial of letrozole as a low-cost IVF protocol in women with poor ovarian response: a preliminary report

BACKGROUND

Use of letrozole, a selective inhibitor of aromatase, reduces the gonadotrophin dose required to induce follicular maturation. We evaluated whether incorporation of letrozole could be an effective low-cost IVF protocol for poor responders.

METHODS

A randomized, controlled, single-blind trial was conducted in the Assisted Reproduction Unit, Institute of Reproductive Medicine, Kolkata, India. Thirty-eight women with a history of poor ovarian response to gonadotrophins were recruited. Thirteen women (Let-FSH group) received letrozole 2.5 mg daily from day 3-7, and recombinant FSH (rFSH) 75 IU/day on days 3 and 8; and 25 women (GnRH-ag-FSH group) underwent long GnRH agonist protocol and stimulated with rFSH (300-450 IU/day). Ovulation was triggered by 10,000 IU of HCG followed by IVF-embryo transfer. The main outcome measures were total dose of rFSH (IU/cycle), terminal estradiol (E2) (pg/ml), numbers of follicles, oocytes retrieved and transferable embryo, endometrial thickness (mm), and pregnancy rate.

RESULTS

Compared with the GnRH-ag-FSH group (2865 +/- 228 IU), the Let-FSH group (150 +/- 0 IU) received a significantly (P < 0.001) lower total dose of FSH. Except for terminal E2, which was significantly higher (P < 0.001) in the GnRH-ag-FSH group (380 +/- 46 pg/ml) than the Let-FSH group (227 +/- 45 pg/ml), the treatment outcomes in all other respects, including pregnancy rate, were statistically comparable.

CONCLUSIONS

Adjunctive use of letrozole may form an effective means of low-cost IVF protocol in poorly responding women.

Predictors of parental adjustment to children's epilepsy in rural India

BACKGROUND

Negative societal attitudes towards disability affect the adjustment of parents when their child is diagnosed with epilepsy. Recent studies have suggested that parental and child outcomes, including adjustment, can be influenced by non-directed social support to mothers of children with disability. The objective of our study was to test the hypothesis that maternal satisfaction with social support, measured at the beginning of treatment, would predict parental adjustment to the child's epilepsy after 1 year of treatment.

METHODS

We enrolled 46 mothers of children aged 6-18 years with epilepsy in the study. We measured social support using the modified Dunst family support scale, and parental adjustment using a locally validated instrument (S-PAM). Correlation was tested using a multiple linear regression model, allowing for confounding variables.

RESULTS

Parental adjustment at outcome was positively independently correlated with satisfaction with social support at baseline,and negatively with severity of the child's epilepsy. The regression model explained 34% of the total variance.

CONCLUSIONS

Taken together with evidence from previous studies, this finding supports the idea that helping parents to find more satisfaction within their (new or existing) social networks will promote adjustment to their child's disability.

Protein A-activated macrophages induce apoptosis in Ehrlich's ascites carcinoma through a nitric oxide-dependent pathway

Protein A (PA) of Staphylococcus aureus has been demonstrated to possess anti-tumor activity against a wide variety of tumors. In the current study we endeavored to obtain a mechanistic insight into PA-mediated Ehrlich's ascites carcinoma (EAC) killing. Our results indicate that PA stimulates generation of nitric oxide (NO) from murine peritoneal macrophages. Nitric oxide in turn induces cytotoxic damage to the tumor cells. Analysis of the morphological features and cell cycle phase distribution pattern of nuclear DNA revealed an induction of apoptosis (appearance of sub-G0/G1 population) in EAC after PA treatment. We have further elaborated the alterations in the expressions of the proto-oncoproteins p53 and Bax, together with a change in the ratio of Bcl-2/Bax in the treated tumor cells, which favor apoptosis. PA-induced apoptosis and changes in the expression of oncoproteins in the tumor cells was prevented by the suppression of NO release by the addition of L-NAME, the competitive NOS inhibitor, suggesting a possible mechanism by which PA exerts its anti-tumor activities involving nitric oxide through the alteration in the expressions of pro-apoptotic proteins.

Solitary plasmacytoma of the skull bone

Solitary plasmacytoma of the bone is an uncommon variety of plasma cell tumour. Here an interesting case of solitary plasmacytoma of the skull bone, which is extremely rare, is being reported.

Randomized placebo-controlled trial of 2,3-dimercapto-1-propanesulfonate (DMPS) in therapy of chronic arsenicosis due to drinking arsenic-contaminated water

BACKGROUND

Chronic arsenic toxicity, producing various clinical manifestations, is currently epidemic in West Bengal, India, Bangladesh, and other regions of the world. 2,3-Dimercapto-1-propanesulfonate, a chelating agent, increases excretion of arsenic in urine to several times the prechelation concentration but the therapeutic efficacy of 2,3-dimercapto-1-propanesulfonate in the management of chronic arsenic toxicity has been incompletely evaluated. We investigated the clinical use of 2,3-dmercapto-1-propanesulfonate in such patients.

METHODS

Twenty-one consecutive patients with chronic arsenicosis were individually randomized into 2 groups: 11 patients (9 males and 2 females, age 30.63+/-11.4 years) received 2,3-dimercapto-1-propanesulfonate 100-mg capsules 4 times a day for 1 week and repeated in the 3rd, 5th, and 7th week with no drug during the intervening period. The other 10 patients (5 males and 5 females, age 34.4+/-14.41 years) were given placebo capsules (resembling 2,3-dimercapto-1-propanesulfonate) in the same schedule. The consumption of arsenic-contaminated water was terminated by all 21 subjects. Initial and posttreatment urinary arsenic excretion was determined in all cases. Sequential excretion of urinary arsenic was determined during the treatment of 2 drug- and 1 placebo-treated cases. The clinical features were evaluated by an objective scoring system before and after treatment. Routine investigation including liver function test and skin biopsy were also done before and after the treatment. Drug-associated toxicity was tabulated.

RESULTS

Therapy with 2,3-dimercapto-1-propanesulfonate caused significant improvement in the clinical condition of chronic arsenicosis patients as evidenced by significant reduction of total clinical scores from 8.90+/-2.84 to 3.27+/-1.73; p < 0.0001. Exposure cessation alone with placebo treatment also reduced clinical scores (8.50+/-1.96 to 5.40+/-2.12; p < 0.003), but the posttreatment total clinical score of 2,3-dimercapto-1-propanesulfonate-treated patients (3.27+/-1.73) was significantly lower than that of placebo-treated patients (5.40+/-2.12; p < 0.01). The most significant improvement was noted in regard to the clinical scores of weakness, pigmentation, and lung disease. No difference was noted between groups in the hematological and biochemical parameters (which were normal) and skin histology before and after treatment. No 2,3-dimercapto-1-propanesulfonate-related adverse effects were noted. Total urinary excretion of arsenic in 2,3-dimercapto-1-propanesulfonate-treated cases increased significantly following drug therapy, with no increase in placebo-treated cases.

CONCLUSION

2,3-Dimercapto-1-propanesulfonate treatment caused significant improvement in the clinical score of patients suffering from chronic arsenic toxicity. Increased urinary excretion of arsenic during the period of therapy is the possible cause of this improvement.

177Lu labelled polyaminophosphonates as potential agents for bone pain palliation

Polyphosphonate ligands labelled with radioisotopes decaying by moderate energy beta emission have shown utility as palliative agents for painful bone metastasis. 177Lu (T(1/2)=6.71 d, Ebetamax=497 keV) has radionuclidic properties suitable for use in palliative therapy of bone metastasis. 177Lu was produced at a high specific activity and excellent radionuclidic purity by thermal neutron bombardment of a target prepared from natural Lu. Three polyaminomethylene phosphonate ligands, abbreviated as EDTMP, DTPMP and TTHMP, were synthesized and radiolabelled with 177Lu. Complexation parameters were optimized to achieve maximum yields (97-99.5%). All the complexes were found to retain their stability at room temperature even 14 days after preparation. Biodistribution studies of the complexes were carried out in Wistar rats. All the complexes showed significant bone uptake (6-6.5%/g in tibia at 3 h post-injection (p.i.)) with rapid clearance from blood and minimum uptake in soft tissues. These studies reveal that 177Lu complexes with the synthesized ligands have a potential use in palliative treatment of painful bone metastasis.

Angle closure glaucoma in nanophthalmos and pigmentary retinal dystrophy: a rare syndrome

The simultaneous occurrence of nanophthalmos, angle closure glaucoma and pigmentary retinal dystrophy documented in the present case represents a rare syndrome.

Mechanisms of curcumin-induced apoptosis of Ehrlich's ascites carcinoma cells

Curcumin, the active ingredient from the spice turmeric (Curcuma longa Linn), is a potent antioxidant and anti-inflammatory agent. It has been recently demonstrated to possess discrete chemopreventive activities. However, the molecular mechanisms underlying such anticancer properties of curcumin still remain unrealized, although it has been postulated that induction of apoptosis in cancer cells might be a probable explanation. In the current study, curcumin was found to decrease the Ehrlich's ascites carcinoma (EAC) cell number by the induction of apoptosis in the tumor cells as evident from flow-cytometric analysis of cell cycle phase distribution of nuclear DNA and oligonucleosomal fragmentation. Probing further into the molecular signals leading to apoptosis of EAC cells, we observed that curcumin is causing tumor cell death by the up-regulation of the proto-oncoprotein Bax, release of cytochrome c from the mitochondria, and activation of caspase-3. The status of Bcl-2 remains unchanged in EAC, which would signify that curcumin is bypassing the Bcl-2 checkpoint and overriding its protective effect on apoptosis.

A novel [186/188Re]-labelled porphyrin for targeted radiotherapy

The concept of labelling a porphyrin, a tumour-avid agent, with a radionuclide to evaluate its potential as a therapeutic modality is reported. A novel water-soluble porphyrin, namely meso-tetrakis[3,4-bis(carboxymethyleneoxy)phenyl]porphyrin, with suitable dicarboxylic acid groups as aromatic substituents in the periphery, was synthesized and characterized. The labelling of this porphyrin with 186/188Re, a beta(-) emitter, was optimized by varying the reaction conditions. The complexation yield was >98% as estimated by paper chromatography in acetone and in saline. The radiochemical purity was found to remain at >98% when stored at 4 degrees C for 24 h. Biodistribution studies in Swiss mice bearing fibrosarcomas showed an uptake of approximately 3.5% per gram of tumour at 30 min post-injection. This uptake in the tumour was retained until 24 h post-injection with major activity showing renal clearance; no significant activity was present in other organs of interest. The tumour/blood and tumour/muscle ratios were observed to be 38 and 5, respectively, at 24 h post-injection, thereby indicating a possible therapeutic potential for tumours.

Clinical profile and outcome in Bacillus endophthalmitis

OBJECTIVE

To study the clinical presentation, microscopic and organismal culture correlation of vitreous, and species-specific outcome in Bacillus endophthalmitis

DESIGN

Retrospective noncomparative case series.

INTERVENTION

Thirty-one culture proven Bacillus endophthalmitis patients between January 1991 and February 1998 underwent vitrectomy and intravitreal antibiotic injection. Lensectomy was combined when considered essential, and on a few occasions intravitreal dexamethasone was added. The patients also received topical and systemic antibiotics. The undiluted vitreous biopsy was the source for microbiologic evaluation (microscopy and culture sensitivity).

MAIN OUTCOME MEASURES

The duration of symptoms, the presenting visual acuity, and influence of intravitreal dexamethasone with intravitreal antibiotics were examined for any statistical correlation with the final visual acuity.

RESULTS

Trauma was the major cause of infection. Vitreous biopsy microscopy demonstrated gram-positive bacillus in 28 of 31 cases, and polymicrobial infection was seen in 12 instances. All Bacillus species were sensitive to gentamicin, followed by vancomycin and ciprofloxacin. Clinical treatment within 7 days of symptoms, use of intravitreal vancomycin, and absence of polymicrobial infection were associated with better visual outcome.

CONCLUSIONS

With appropriate treatment that essentially consists of vitrectomy and intravitreal antibiotics, patients with Bacillus endophthalmitis are likely to benefit in many instances. Gram-positive bacilli detected on vitreous microscopy should be empirically treated as Bacillus species unless otherwise proved.

Excimer laser revascularisation: current indications, applications and techniques

The ultraviolet pulsed excimer laser (308 nm wavelength) is currently the only laser approved by the FDA for percutaneous intervention in patients with ischemic coronary artery disease. The clinical presentation of the treated patients varies from stable and unstable angina to acute myocardial infarction. Potential advantages of excimer laser revascularisation in acute coronary syndromes and in ischaemic obstructive peripheral vascular disease include concomitant plaque debulking and thrombus removal; absence of systemic lytic state; shortened thrombus clearing time and facilitation of adjunct balloon angioplasty and stenting. Improved understanding of laser-tissue interactions and positive clinical outcomes through the use of safe lasing techniques have led to expansion of indications/applications for laser angioplasty. These include stent restenosis, complex lesions and thrombotic stenoses, bifurcation lesions, balloon failure, total occlusions, focal saphenous vein graft lesions and peripheral arterial obstructions. The excimer laser can be effectively utilised in patients with depressed left ventricular ejection fraction and does not require implantation of a temporary pacemaker as no-reflow phenomenon and severe arrhythmias are rarely encountered. Careful case selection, proper utilisation of equipment and incorporation of efficient lasing techniques play a crucial role in effective and safe cardiovascular laser applications.

Evaluation of glutaraldehyde and povidone iodine for sterilization of wide-field contact vitrectomy lenses

BACKGROUND AND OBJECTIVE

Wide-field vitrectomy contact lenses are currently sterilized with ethylene oxide gas, and other lenses with autoclaving. To maintain a large inventory or possibly run the risk of loss of lens quality with repeated autoclaving, glutaraldehyde 2% and povidone iodine 5% solution were evaluated as possible sterilizing agents.

MATERIALS AND METHODS

Ethylene oxide presterilized lenses were contaminated with known concentrations (10(5) organisms/mL) of bacteria (S. epidemidis, P. aeruginosa, B. subtilis), and fungi (A. flavus, C. albicans) for 5 minutes. The test lenses were treated with glutaraldehyde or povidone iodine for 5, 10, 30, 60, and 120 minutes, and controls with sterilized water for a similar duration. Following treatment, both test and control lenses were sampled with sterile cotton swabs. The swabs were cultured for bacteria (tryptone soya broth 48 hours), and fungi (Saubourd's dextrose broth 5 days).

RESULTS

The culture was negative for both glutaraldehyde- and povidone iodine-treated lenses against all organisms at all time points except B subtilis, which needed 120 minutes treatment.

CONCLUSION

Two hours contact time with glutaraldehyde 2% or providone iodine 5% can sterilize vitrectomy contact lenses against common bacteria and fungi without affecting lens quality.

Potential (166)Ho radiopharmaceuticals for intravascular radiation therapy (IVRT)-I: [(166)Ho] holmium labeled ethylene dicysteine

The use of beta(-) emitting radionuclides in the control of restenosis in post angioplasty patients is currently under intense investigation at many leading cardiovascular research centers. (32)P coated metallic stents, (192)Ir wire source and balloons filled with an appropriate radionuclide solution such as of (188)Re, attached to catheter are being studied. (166)Ho has comparable radionuclidic properties to that of (188)Re, can be more easily produced and hence is an attractive alternative to (188)Re. Ethylene dicysteine complex of (166)Ho was prepared and its pharmacological behavior studied. Optimum conditions for the preparation of complex with respect to the reaction time, ligand concentration, pH of the reaction mixture as well as reaction temperature were standardized. The stability of the labeled complex at room temperature as well as at 4 degrees C was determined. Biodistribution pattern of the injected complex in Wistar rats was estimated at 10 min, 30 min and 3 h post injection. This study indicated that >90% of the injected (166)Ho-EC complex was excreted in urine within 3 h post injection, with insignificant retention in any major organ. These studies reveal that (166)Ho-EC could be a viable substitute for (188)Re compounds in radioactive liquid-filled balloon IVRT.

Studies on central nervous system function in diabetes mellitus

Fifty-seven insulin dependent (IDDM) and non-insulin dependent (NIDDM) diabetic patients and 25 controls were studied. Patients with history of strokes, hypoglycaemia, hearing impairment, diabetic retinopathy, etc, were excluded. Clinical examination of central nervous system (CNS) and computerised tomography scan of brain were absolutely normal in all cases. Neuroelectrophysiological tests done were the visual evoked potential (VEP), brainstem auditory evoked response (BAER) and somatosensory evoked potential (SEP). The mean VEP latency was significantly raised in both NIDDM and IDDM compared with controls. The mean BAER and SEP latencies were both significantly raised in NIDDM but not in IDDM. The percentage of cases with abnormally raised CNS latencies were as follows: In NIDDM, VEP-16.7%, BAER-50% and SEP-26.7%; in IDDM, VEP-11.1%, BAER-14.8% and SEP-18.5%. Thus, subclinical CNS dysfunction is common in diabetes mellitus particularly in NIDDM and this can be reliably detected by measuring the CNS latencies, specially VEP.

Protection of apoptotic cell death by protein A

The word "Apoptosis" or pragrammed cell death is described as the ultimate end of multiple cellular events converging from numerous initiating events to the ultimate death of a cell or organism. Several processes, such as initiation of death signals at the plasma membrane, expression of pro-apoptotic oncoproteins, activation of death proteases, endonucleases etc., that ultimately coalesce to a common irreversible execution phase, lead to cell demise. Counteracting the death signals are cell survival factors. A balance between the cell death and cell survival factors plays a major role in the decision making process as to whether a cell should die or must live. It is, therefore, hypothesized that if the balance can be shifted in favor of cell survival, one might be able to arrest the aging process, save the injured cells or else if the balance is shifted toward cell-kill it might help destroy tumors and other undesirable cells. Protein A (PA) of Staphylococcus aureus has been found to have multifarious biological response modifying properties. It has been shown to possess anti-tumor, antitoxic, anti-parasitic and antifungal activities. It also acts as a potent immunostimulator. PA can protect bone marrow progenitor cells from zidovudin(AZT)-induced apoptosis and can stimulate immunocyte proliferation, thereby helping to replenish/restore the depleted hematopoietic cell pool. Such ability to replenish hematopoietic cells is a common property of PA observed against a number of toxic drugs/chemicals, such as cyclophosphamide, benzene, aflatoxin, salmonella endotoxin, etc. Interestingly, it was further demonstrated in our laboratory that PA can selectively kill tumor cells without affecting normal cells of the host. A search for the mechanisms of PA action revealed that this bacterial protein could shift the balance between pro- and anti-apoptotic proteins in favor of survival in normal cells, but in favor of cell death in tumor cells at a particular dose level. This unique property of PA suggests that controlled use of such type of Biological Response Modifier might help in controlling both cell growth and death phenomena.

New approaches in the management of choroidal neovascular membrane in age-related macular degeneration

Age-related macular degeneration (AMD) is a leading cause of blindness in the elderly population. The prevalence is reported to be 1.2-1.4% in several population-based epidemiological studies. Currently 25-30 million people worldwide are blind due to AMD. With the aging world population it is bound to increase significantly, and could become a significant public health problem in next two decades, with serious socio-economic implications. Several strategies are today available to treat the wet form of AMD, which is responsible for significant visual loss. These were until recently confined to laser photocoagulation, and subretinal surgery, but today two other modalities, namely, radiation and photodynamic therapy, are available. These treatment modalities however, are aimed at preservation of vision only, and not at reversing the process of the disease. Further research on antiangiogenic drugs and gene therapy could significantly help AMD patients.

Polyunsaturated fatty acid-specific elongation enzymes

We have isolated a novel gene (GLELO) from Mortierella alpina and its homologue (CEELO1) from Caenorhabditis elegans and demonstrate the involvement of their encoded proteins in the elongation of C(18) polyunsaturated fatty acids.

High-level expression of biologically active human prolactin from recombinant baculovirus in insect cells

We examined the feasibility of high-level production of recombinant human prolactin, a multifunctional protein hormone, in insect cells using a baculovirus expression system. The human prolactin cDNA with and without the secretory signal sequence was cloned into pFastBac1 baculovirus vector under the control of polyhedrin promoter. Prolactin was produced upon infection of either Sf9 or High-Five cells with the recombinant baculovirus containing the human prolactin cDNA. The production of recombinant prolactin varied from 20 to 40 mg/L of monolayer culture, depending on the cell types. The prolactin polypeptide with its own secretory signal was secreted into the medium. N-terminal amino acid sequence analysis of the recombinant polypeptide purified from the culture medium indicated that the protein was processed similar to human pituitary prolactin. Carbohydrate analysis of the purified protein indicated that a fraction of the recombinant prolactin made in insect cells appeared to be glycosylated. Also, both secreted and nonsecreted forms of the recombinant prolactin in insect cells were biologically equivalent to the native human prolactin (pituitary derived) in the Nb2 lymphoma cell proliferation assay.

188Re-ethylene dicysteine: a novel agent for possible use in endovascular radiation therapy

Several agents, such as 188ReO4-, 188Re-MAG3 and 188Re-DTPA are currently under investigation as radiation sources in liquid-filled balloons for prevention of restenosis following coronary angioplasty. Bearing in mind the risk factor associated with leakage of radioactivity in the event of balloon rupture, the criteria sought in selecting suitable agents for endovascular radiation therapy (EVRT) are rapid clearance and low dose to vital organs. Since 99Tcm labelled ethylene dicysteine (EC) is a well established agent for renal tubular function imaging, the use of 186Re-ethylene dicysteine as a potential agent for prevention of restenosis after angioplasty has been evaluated previously. Therefore, it was of interest to evaluate the applicability of the more potential isotope of rhenium, 188Re, a high energy beta-emitter (Ebetamax = 2.12 MeV) with a suitable T 1/2 = 16.9 h, obtainable carrier-free from the 188W-188Re generator, as an attractive and alternative radionuclide for labelling with L,L-EC. In this paper, the preparation and pharmacological behaviour of the 188Re complex of ethylene dicysteine are reported. The complex can be prepared in high yields (99.5%) under optimized conditions of pH 2-3, at a ligand concentration of 15 mM, 50 microg (0.18 mM) carrier rhenium and using 2 mg x mL(-1) stannous chloride. On storage at 4 degrees C, the RC purity was more than 97% after 48 h when prepared under optimum conditions. Biodistribution studies in Wistar rats showed the desired characteristics of fast blood clearance and low retention of activity in the vital organs (< 2% in intestine, < 1% in stomach, < 0.5% in liver) with a high renal excretion (90.65+/-0.6%) at 3 h post-injection. These results confirm the advantages of using the 188Re-EC complex compared with perrhenate and other rhenium radiopharmaceuticals currently being used in balloons for EVRT.